Physician Radiation Exposure During Endomyocardial Biopsy and Right Heart Catheterization.

BACKGROUND: Cardiologists performing coronary angiography (CA) and percutaneous coronary intervention (PCI) are at risk of health problems related to chronic occupational radiation exposure. Unlike during CA and PCI, physician radiation exposure during right heart catheterization (RHC) and endomyocardial biopsy (EMB) has not been adequately studied. The objective of this study was to assess physicians' radiation doses during RHC with and without EMB and compare them to those of CA and PCI. METHODS: Procedural head-level physician radiation doses were collected by real-time dosimeters. Radiation-dose metrics (fluoroscopy time, air kerma [AK] and dose area product [DAP]), and physician-level radiation doses were compared among RHC, RHC with EMB, CA, and PCI. RESULTS: Included in the study were 351 cardiac catheterization procedures. Of these, 36 (10.3%) were RHC, 42 (12%) RHC with EMB, 156 (44.4%) CA, and 117 (33.3%) PCI. RHC with EMB and CA had similar fluoroscopy time. AK and DAP were progressively higher for RHC, RHC with EMB, CA, and PCI. Head-level physician radiation doses were similar for RHC with EMB vs CA (P = 0.07). When physicians' radiation doses were normalized to DAP, RHC and RHC with EMB had the highest doses. CONCLUSION: Physicians' head-level radiation doses during RHC with EMB were similar to those of CA. After normalizing to DAP, RHC and RHC with EMB were associated with significantly higher physician radiation doses than CA or PCI. These observations suggest that additional protective measures should be undertaken to decrease physicians' radiation exposure during RHC and, in particular, RHC with EMB.

Robotically performed diagnostic coronary angiography.

OBJECTIVE: This study was performed to investigate the efficacy and safety of robotic diagnostic coronary angiography. BACKGROUND: Robotic percutaneous coronary intervention is associated with marked reductions in physician radiation exposure. Development of robotic diagnostic coronary angiography might similarly impact occupational safety. METHODS: Stable patients referred for coronary angiography were prospectively enrolled. After obtaining vascular access, diagnostic catheters were manually advanced over a wire to the ascending aorta. All subsequent catheter movements were performed robotically. The primary endpoint was procedural success, defined as robotic completion of coronary angiography without conversion to a manual procedure and the absence of procedural major adverse cardiovascular events (MACE-cardiac death, cardiac arrest, or stroke) and major angiographic complications (coronary/aortic dissection or embolization). The primary hypothesis was that the observed rate of the primary endpoint, evaluated at the completion of coronary angiography, would meet a pre-specified performance goal of 74.5%. RESULTS: Among 46 consecutive patients (age 67 ± 12 years; 69.6% male), diagnostic coronary angiography was completed robotically in all cases without the need for manual conversion and without any MACE or major angiographic complications. Thus, procedural success was 100%, which was significantly higher than the pre-specified performance goal (p < 0.001). Robotic coronary angiography was completed using 2 [2, 3] catheters per case with a median procedural time of 15 [11, 20] minutes. CONCLUSIONS: Robotic diagnostic coronary angiography was performed with 100% procedural success and no observed complications. These results support the performance of future studies to further explore robotic coronary angiography.

Suspended lead suit and physician radiation doses during coronary angiography.

OBJECTIVE: This study was performed to evaluate physician radiation doses with the use of a suspended lead suit. BACKGROUND: Interventional cardiologists face substantial occupational risks from chronic radiation exposure and wearing heavy lead aprons. METHODS: Head-level physician radiation doses, collected using real-time dosimeters during consecutive coronary angiography procedures, were compared with the use of a suspended lead suit versus conventional lead aprons. Multiple linear regression analyses were completed using physician radiation doses as the response and testing patient variables (body mass index, age, sex), procedural variables (right heart catheterization, fractional flow reserve, percutaneous coronary intervention, radial access), and shielding variables (radiation-absorbing pad, accessory lead shield, suspended lead suit) as the predictors. RESULTS: Among 1054 coronary angiography procedures, 691 (65.6%) were performed with a suspended lead suit and 363 (34.4%) with lead aprons. There was no significant difference in dose area product between groups (61.7 [41.0, 94.9] mGy·cm2 vs. 64.6 [42.9, 96.9] mGy·cm2 , p = 0.20). Median head-level physician radiation doses were 10.2 [3.2, 35.5] µSv with lead aprons and 0.2 [0.1, 0.9] µSv with a suspended lead suit (p < 0.001), representing a 98.0% reduced dose with suspended lead. In the fully adjusted regression model, the use of a suspended lead suit was independently associated with a 93.8% reduction (95% confidence interval: -95.0, -92.3; p < 0.001) in physician radiation dose. CONCLUSION: Compared to conventional lead aprons, the use of a suspended lead suit during coronary angiography was associated with marked reductions in head-level physician radiation doses.

Target Lesion Lipid Content Detected by Near-Infrared Spectroscopy After Stenting and the Risk of Subsequent Target Lesion Failure.

[Figure: see text].

Robotic telestenting performance in transcontinental and regional pre-clinical models.

OBJECTIVES: This study was conducted to evaluate the association of geographic distance with robotic telestenting performance by comparing performance measures in transcontinental and regional pre-clinical models of telestenting. BACKGROUND: Robotic telestenting, in which percutaneous coronary intervention (PCI) is performed on a remotely located patient, might improve PCI access, but has not been attempted over vast distances likely required to reach many underserved regions. METHODS: Telestenting performance was compared in regional (Boston to New York [206 miles]) and transcontinental (Boston to San Francisco [3,085 miles]) ex vivo models of telestenting, wherein a physician in Boston attempted robotic PCI on endovascular simulators in New York and San Francisco, respectively. PCI was attempted over both wired and fifth generation (5G)-wireless networks. Outcome measures included procedural success, procedural time, and perceived latency. RESULTS: Procedural success was achieved in 20 consecutive target lesions in the regional model and in 16 consecutive target lesions in the transcontinental model. The transcontinental model had a greater latency than the regional model over both wired (121.5 ± 2.4 ms vs. 67.8 ± 0.9 ms; p < .001) and 5G-wireless networks (162.5 ± 1.1 ms vs. 86.6 ± 0.6 ms; p < .001), but perceived latencies were graded "imperceptible" in all cases in both models. Transcontinental and regional models did not have significantly different procedural times over wired (4.1 ± 1.9 min vs. 9.0 ± 7.1 min; p = .051) or 5G-wireless (3.0 ± 0.6 vs. 6.3 ± 1.2; p = .36) networks. CONCLUSIONS: Transcontinental robotic manipulation of coronary devices is now possible and was not associated with adverse performance compared to robotic telestenting conducted regionally.

Unloading the Left Ventricle Before Reperfusion in Patients With Anterior ST-Segment-Elevation Myocardial Infarction.

BACKGROUND: In ST-segment-elevation myocardial infarction (STEMI), infarct size correlates directly with heart failure and mortality. Preclinical testing has shown that, in comparison with reperfusion alone, mechanically unloading the left ventricle (LV) before reperfusion reduces infarct size and that 30 minutes of unloading activates a cardioprotective program that limits reperfusion injury. The DTU-STEMI pilot trial (Door-To-Unload in STEMI Pilot Trial) represents the first exploratory study testing whether LV unloading and delayed reperfusion in patients with STEMI without cardiogenic shock is safe and feasible. METHODS: In a multicenter, prospective, randomized exploratory safety and feasibility trial, we assigned 50 patients with anterior STEMI to LV unloading by using the Impella CP followed by immediate reperfusion (U-IR) versus delayed reperfusion after 30 minutes of unloading (U-DR). The primary safety outcome was a composite of major adverse cardiovascular and cerebrovascular events at 30 days. Efficacy parameters included the assessment of infarct size by using cardiac magnetic resonance imaging. RESULTS: All patients completed the U-IR (n=25) or U-DR (n=25) protocols with respective mean door-to-balloon times of 72 versus 97 minutes. Major adverse cardiovascular and cerebrovascular event rates were not statistically different between the U-IR versus U-DR groups (8% versus 12%, respectively, P=0.99). In comparison with the U-IR group, delaying reperfusion in the U-DR group did not affect 30-day mean infarct size measured as a percentage of LV mass (15±12% versus 13±11%, U-IR versus U-DR, P=0.53). CONCLUSIONS: We report that LV unloading using the Impella CP device with a 30-minute delay before reperfusion is feasible within a relatively short time period in anterior STEMI. The DTU-STEMI pilot trial did not identify prohibitive safety signals that would preclude proceeding to a larger pivotal study of LV unloading before reperfusion. An appropriately powered pivotal trial comparing LV unloading before reperfusion to the current standard of care is required. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03000270.

Network latency and long-distance robotic telestenting: Exploring the potential impact of network delays on telestenting performance.

OBJECTIVE: This study evaluated the impact of network latency on telestenting performance. BACKGROUND: The feasibility of long-distance robotic telestenting was recently demonstrated, yet the impact of network performance on telestenting remains unknown. METHODS: Ex vivo and in vivo telestenting models were constructed by connecting a robotic drive over a wired network to a robotic control system up to 103 miles away. During consecutive attempts to robotically wire a coronary artery, investigators randomly added signal latencies from 0 to 1,000 ms. Outcomes included wiring success, wiring time (time to advance wire to preselected target landmark), and perceived latency score (5 = imperceptible; 4 = noticeable but minor; 3 = noticeable; 2 = noticeable and major; 1 = unacceptable). RESULTS: Wiring success was achieved in 95 of 95 attempts in the ex vivo model and in 57 of 57 attempts in vivo. No significant difference in wiring time was observed across added latencies from 0 to 1,000 ms in the ex vivo (p = .64) or in vivo (p = .40) models. Compared to an added latency of 0 ms, perceived latency scores were not significantly different for added latencies of 150 and 250 ms (p = NS for both), but were significantly lower for latencies ≥400 ms (p < .001). CONCLUSIONS: Added latencies up to 250 ms were not associated with perceived latency, but latencies ≥400 ms were perceptible. Based on these findings, future telestenting studies should utilize networks with latencies ≤250 ms if perceived latency is to be avoided.

Contemporary use of and outcomes associated with ultra-low contrast volume in patients undergoing percutaneous coronary interventions.

BACKGROUND: The risk of contrast-induced acute kidney injury (CI-AKI) increases in a nonlinear fashion with increasing volume of contrast media. Prior studies recommend limiting contrast volume to less than three times the estimated creatinine clearance (CC). Recently, a number of operators have reported successful percutaneous coronary intervention (PCI) using even lower volumes of contrast. OBJECTIVES: To evaluate the prevalence and outcomes associated with ultra-low contrast volume among patients undergoing PCI. METHODS: We assessed the prevalence and outcomes associated with use of ultra-low contrast volume among 75 393 patients undergoing PCI in Michigan between July 2014 and June 2017 in the BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) registry. Ultra-low contrast volume was defined as contrast volume less than or equal to the patient's estimated CC. Patients receiving dialysis at the time of the procedure were excluded. RESULTS: Ultra-low contrast volume was used in 13% of procedures with the majority of these patients being at low risk of renal complications. Compared with patients who received a contrast volume between one and three times the CC, use of ultra-low volume of contrast was associated with a significantly lower incidence of AKI (aOR 0.682, 95% CI 0.566-0.821, P < 0.001) and a lower incidence of need for dialysis (aOR = 0.341, 95% CI 0.165-0.704, P = 0.003). These benefits were most evident in the patients with a high baseline predicted risk of AKI. CONCLUSIONS: A small but clinically significant number of patients are treated with ultra-low contrast volume. Ultra-low contrast volume use is associated with a significant reduction in the incidence of AKI or need for dialysis. It may be prudent to consider this new threshold when performing PCI on patients who are at an increased risk of AKI.

Confirmation of the Intracoronary Near-Infrared Spectroscopy Threshold of Lipid-Rich Plaques That Underlie ST-Segment-Elevation Myocardial Infarction.

OBJECTIVE: In a previous exploratory analysis, intracoronary near-infrared spectroscopy (NIRS) found the majority of culprit lesions in ST-segment-elevation myocardial infarction (STEMI) to contain a maximum lipid core burden index in 4 mm (maxLCBI4mm) of >400. This initial study was limited by a small sample size, enrollment at a single center, and post hoc selection of the maxLCBI4mm ≥400 threshold. This study was designed a priori to substantiate the ability of NIRS to discriminate STEMI culprit from nonculprit segments and to confirm the performance of the maxLCBI4mm ≥400 threshold. APPROACH AND RESULTS: At 2 centers in the United States and Sweden, 75 STEMI patients underwent intracoronary NIRS imaging after establishing thrombolysis in myocardial infarction 3 flow, but before stenting. Blinded core laboratory analysis defined the culprit segment as the 10-mm segment distal to the proximal angiographic culprit margin. The remaining vessel was divided into contiguous 10-mm nonculprit segments. The maxLCBI4mm of culprit segments (median [interquartile range]: 543 [273-756]) was 4.4-fold greater than nonculprit segments (median [interquartile range]: 123 [0-307]; P<0.001). Receiver-operating characteristic analysis demonstrated that maxLCBI4mm differentiated culprit from nonculprit segments with high accuracy (c-statistic=0.83; P<0.001). A threshold maxLCBI4mm ≥400 identified STEMI culprit segments with a sensitivity of 64% and specificity of 85%. CONCLUSIONS: This study substantiates the ability of NIRS to accurately differentiate STEMI culprit from nonculprit segments and confirms that a threshold maxLCBI4mm ≥400 is detected by NIRS in the majority of STEMI culprits.

Near-Infrared Spectroscopy Enhances Intravascular Ultrasound Assessment of Vulnerable Coronary Plaque: A Combined Pathological and In Vivo Study.

OBJECTIVES: Pathological studies demonstrate the dual significance of plaque burden (PB) and lipid composition for mediating coronary plaque vulnerability. We evaluated relationships between intravascular ultrasound (IVUS)-derived PB and arterial remodeling with near-infrared spectroscopy (NIRS)-derived lipid content in ex vivo and in vivo human coronary arteries. APPROACH AND RESULTS: Ex vivo coronary NIRS and IVUS imaging was performed through blood in 116 coronary arteries of 51 autopsied hearts, followed by 2-mm block sectioning (n=2070) and histological grading according to modified American Heart Association criteria. Lesions were defined as the most heavily diseased 2-mm block per imaged artery on IVUS. IVUS-derived PB and NIRS-derived lipid core burden index (LCBI) of each block and lesion were analyzed. Block-level analysis demonstrated significant trends of increasing PB and LCBI across more complex atheroma (Ptrend <0.001 for both LCBI and PB). Lesion-based analyses demonstrated the highest LCBI and remodeling index within coronary fibroatheroma (Ptrend <0.001 and 0.02 versus all plaque groups, respectively). Prediction models demonstrated similar abilities of PB, LCBI, and remodeling index for discriminating fibroatheroma (c indices: 0.675, 0.712, and 0.672, respectively). A combined PB+LCBI analysis significantly improved fibroatheroma detection accuracy (c index 0.77, P=0.028 versus PB; net-reclassification index 43%, P=0.003), whereas further adding remodeling index did not (c index 0.80, P=0.27 versus PB+LCBI). In vivo comparisons of 43 age- and sex-matched patients (to the autopsy cohort) undergoing combined NIRS-IVUS coronary imaging yielded similar associations to those demonstrated ex vivo. CONCLUSIONS: Adding NIRS to conventional IVUS-derived PB imaging significantly improves the ability to detect more active, potentially vulnerable coronary atheroma.

Invasive evaluation of plaque morphology of symptomatic superficial femoral artery stenoses using combined near-infrared spectroscopy and intravascular ultrasound.

The purpose of this study is to characterize the plaque morphology of severe stenoses in the superficial femoral artery (SFA) employing combined near-infrared spectroscopy and intravascular ultrasound (NIRS-IVUS). Atherosclerosis is the most common cause of symptomatic peripheral arterial disease. Plaque composition of SFA stenoses has been characterized as primarily fibrous or fibrocalcific by non-invasive and autopsy studies. NIRS has been validated to detect lipid-core plaque (LCP) in the coronary circulation. We imaged severe SFA stenoses with NIRS-IVUS prior to revascularization in 31 patients (46 stenoses) with Rutherford claudication ⩾ class 3. Angiographic parameters included lesion location and stenosis severity. IVUS parameters included plaque burden and presence of calcium. NIRS images were analyzed for LCP and maximum lipid-core burden index in a 4-mm length of artery (maxLCBI4mm). By angiography, 38 (82.6%) lesions were calcified and 9 (19.6%) were chronic total occlusions. Baseline stenosis severity and lesion length were 86.0 ± 11.0% and 36.5 ± 46.5 mm, respectively. NIRS-IVUS identified calcium in 45 (97.8%) lesions and LCP in 17 (37.0%) lesions. MaxLCBI4mm was 433 ± 244. All lesions with LCP also contained calcium; there were no non-calcified lesions with LCP. In conclusion, this is the first study of combined NIRS-IVUS in patients with PAD. NIRS-IVUS demonstrates that nearly all patients with symptomatic severe SFA disease have fibrocalcific plaque, and one-third of such lesions contain LCP. These findings contrast with those in patients with acute coronary syndromes, and may have implications regarding the pathophysiology of atherosclerosis in different vascular beds.

Detection by near-infrared spectroscopy of large lipid cores at culprit sites in patients with non-ST-segment elevation myocardial infarction and unstable angina.

OBJECTIVE: This study was performed to assess the lipid burden of culprit lesions in non-ST-segment elevation myocardial infarction (non-STEMI) and unstable angina (UA). BACKGROUND: A recent intracoronary near-infrared spectroscopy (NIRS) study showed 85% of STEMI culprit lesions have a maximum lipid core burden index in 4-mm (maxLCBI(4mm)) ≥ 400. Whether culprit lesions in non-STEMI and UA are characterized by a similarly large lipid burden is unknown. METHODS: We studied 81 non-STEMI and UA patients undergoing culprit vessel NIRS imaging before stenting. Culprit segments were compared to all nonoverlapping 10-mm nonculprit segments for maxLCBI(4mm). Culprit segments in non-STEMI and UA were compared for the frequency of maxLCBI(4mm) ≥ 400. RESULTS: Among 81 patients (53.1% non-STEMI, 46.9% UA), non-STEMI culprit segments had a 3.4-fold greater maxLCBI(4mm) than nonculprits (448 ± 229 vs 132 ± 154, P < 0.001) and UA culprit segments had a 2.6-fold higher maxLCBI(4mm) than nonculprits (381 ± 239 vs 146 ± 175, P < 0.001). NIRS detected a maxLCBI(4mm) ≥ 400 in 63.6% of culprit segments in NSTEMI and in 38.5% of culprit segments in UA (P = 0.02). Against a background of nonculprit segments, maxLCBI(4mm) ≥ 400 had a sensitivity of 63.6% and specificity of 94.0% for culprit segments in NSTEMI and a sensitivity of 38.5% and specificity of 89.8% for culprit segments in UA. CONCLUSIONS: Large lipid cores similar to those recently detected by NIRS at STEMI culprit sites were frequently observed at culprit sites in patients with non-STEMI and UA. These findings support ongoing prospective trials designed to determine if NIRS can provide site-specific prediction of future acute coronary events.

Contemporary Trends and Outcomes of Intravascular Lithotripsy in Percutaneous Coronary Intervention: Insights From BMC2.

BACKGROUND: With an aging population and an increase in the comorbidity burden of patients undergoing percutaneous coronary intervention (PCI), the management of coronary calcification for optimal PCI is critical in contemporary practice. OBJECTIVES: This study sought to examine the trends and outcomes of coronary intravascular lithotripsy (IVL), rotational/orbital atherectomy, or both among patients who underwent PCI in Michigan. METHODS: We included all PCIs between January 1, 2021, and June 30, 2022, performed at 48 Michigan hospitals. Outcomes included in-hospital major adverse cardiac events (MACEs) and procedural success. RESULTS: IVL was used in 1,090 patients (2.57%), atherectomy was used in 1,743 (4.10%) patients, and both were used in 240 patients (0.57% of all PCIs). IVL use increased from 0.04% of PCI cases in January 2021 to 4.28% of cases in June 2022, ultimately exceeding the rate of atherectomy use. The rate of MACEs (4.3% vs 5.4%; P = 0.23) and procedural success (89.4% vs 89.1%; P = 0.88) were similar among patients treated with IVL compared with atherectomy, respectively. Only 15.6% of patients treated with IVL in contemporary practice were similar to the population enrolled in the pivotal IVL trials. Among such patients (n = 169), the rate of MACEs (0.0%) and procedural success (94.7%) were similar to the outcomes reported in the pivotal IVL trials. CONCLUSIONS: Since its introduction in February 2021, coronary IVL use has steadily increased, exceeding atherectomy use in Michigan by February 2022. Contemporary use of IVL and atherectomy is generally associated with high rates of procedural success and low rates of complications.

Statewide Initiative to Reduce Patient Radiation Doses During Percutaneous Coronary Intervention.

BACKGROUND: Improved radiation safety practices are needed across hospitals performing percutaneous coronary intervention (PCI). This study was performed to assess the temporal trend in PCI radiation doses concurrent with the conduct of a statewide radiation safety initiative. METHODS: A statewide initiative to reduce PCI radiation doses was conducted in Michigan between 2017 and 2021 and included focused radiation safety education, reporting of institutional radiation doses, and implementation of radiation performance metrics for hospitals. Using data from a large statewide registry, PCI discharges between July 1, 2016, and July 1, 2022, having a procedural air kerma (AK) recorded were analyzed for temporal trends. A multivariable regression analysis was performed to determine whether declines in procedural AK over time were attributable to changes in known predictors of radiation doses. RESULTS: Among 131 619 PCI procedures performed during the study period, a reduction in procedural AK was observed over time, from a median dose of 1.46 (0.86-2.37) Gy in the first year of the study to 0.97 (0.56-1.64) Gy in the last year of the study (P<0.001). The proportion of cases with an AK ≥5 Gy declined from 4.24% to 0.86% over the same time period (P<0.0001). After adjusting for variables known to impact radiation doses, a 1-year increase in the date of PCI was associated with a 7.61% (95% CI, 7.38%-7.84%) reduction in procedural AK (P<0.0001). CONCLUSIONS: Concurrent with the conduct of a statewide initiative to reduce procedural radiation doses, a progressive and significant decline in procedural radiation doses was observed among patients undergoing PCI in the state of Michigan.

Multimodality direct coronary imaging with combined near-infrared spectroscopy and intravascular ultrasound: initial US experience.

Recent studies emphasize the importance of direct intracoronary imaging techniques that provide insights regarding not only lesion architecture but also plaque composition, particularly the presence or absence of lipid-core plaque (LCP). Intracoronary near-infrared spectroscopy (NIRS) is the only validated FDA approved device for in vivo detection of LCP. A recently introduced catheter provides simultaneous NIRS spectral data coregistered with standard intravascular ultrasound (IVUS) images in a single intracoronary pullback. The present series of cases illustrates the unique data obtained by this combined NIRS-IVUS device and highlights its potential clinical applications. © 2012 Wiley Periodicals, Inc.

Near-Infrared Spectroscopy-Guided Percutaneous Coronary Intervention: Practical Applications and Available Evidence.

Intracoronary near-infrared spectroscopy (NIRS) has been extensively validated against the gold standard of histopathology to identify lipid-rich plaque. NIRS is currently in clinical use as a combined multimodality imaging catheter with intravascular ultrasonography. When used before PCI, NIRS has clinical utility in determining the mechanism underlying acute coronary syndromes and can be used to guide stent length selection and identify the risk of periprocedural myocardial infarction. When used after PCI, NIRS can identify vulnerable patients at increased risk of future patient-level cardiovascular events and can detect vulnerable plaques at increased risk of future site-specific coronary events.

Clinical outcomes of acute myocardial infarction arising from non-lipid-rich plaque determined by NIRS-IVUS.

Acute myocardial infarction (AMI) can rarely arise from non-lipid-rich coronary plaques. This study sought to compare the clinical outcomes after percutaneous coronary intervention (PCI) between AMI showing maximum lipid-core burden index in 4 mm (maxLCBI4mm) < 400 and ≥ 400 in the infarct-related lesions assessed by near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS). We investigated 426 AMI patients who underwent NIRS-IVUS in the infarct-related lesions before PCI. Major adverse cardiovascular events (MACE) were defined as the composite of cardiac death, non-fatal MI, clinically driven target lesion revascularization (TLR), clinically driven non-TLR, and congestive heart failure requiring hospitalization. 107 (25%) patients had infarct-related lesions of maxLCBI4mm < 400, and 319 (75%) patients had those of maxLCBI4mm ≥ 400. The maxLCBI4mm < 400 group had a younger median age at onset (68 years [IQR: 57-78 years] vs. 73 years [IQR: 64-80 years], P = 0.007), less frequent multivessel disease (39% vs. 51%, P = 0.029), less frequent TIMI flow grade 0 or 1 before PCI (62% vs. 75%, P = 0.007), and less frequent no-reflow immediately after PCI (5% vs. 11%, P = 0.039). During a median follow-up period of 31 months [IQR: 19-48 months], the frequency of MACE was significantly lower in the maxLCBI4mm < 400 group compared with the maxLCBI4mm ≥ 400 group (4.7% vs. 17.2%, P = 0.001). MaxLCBI4mm < 400 was an independent predictor of MACE-free survival at multivariable analysis (hazard ratio: 0.36 [confidence interval: 0.13-0.98], P = 0.046). MaxLCBI4mm < 400 measured by NIRS in the infract-related lesions before PCI was associated with better long-term clinical outcomes in AMI patients.

Preprocedural Anxiety in Adults With Congenital Heart Disease: The PANIC Study.

Background: Preprocedural anxiety may have detrimental effects both cognitively and physiologically. Objectives: The objective of this study was to determine the association between state (situational) and trait (persistent in everyday life) anxiety and differences between the adult congenital heart disease (ACHD) and acquired heart disease populations. Methods: The State-Trait Anxiety Inventory and financial stress scale were administered to adults with acquired and CHD at 4 tertiary referral centers in the United States prior to cardiac catheterization. Student's t-test and least absolute shrinkage and selection operator regression analyses were used to assess differences in anxiety between groups and identify the optimal model of predictors of anxiety. Results: Of the 291 patients enrolled, those with CHD (n = 91) were younger (age 41.3 ± 16.3 years vs 64.7 ± 11.3 years, P < 0.001), underwent more cardiac surgeries (P < 0.001), and had higher levels of trait anxiety (t[171] = 2.62, P = 0.001, d = 0.33). There was no difference in state anxiety between groups (t[158.65] = 1.37, P = 0.17, d = 0.18). State anxiety was singularly associated with trait anxiety. Trait anxiety was negatively associated with age and positively associated with state anxiety and financial stress. Patients with CHD of great complexity were more trait (F[2,88] = 4.21, P = 0.02) and state anxious (F[2,87] = 4.59, P = 0.01), though with relatively small effect size. Conclusions: Trait anxiety levels are higher in the ACHD population and directly associated with state anxiety. Specialists caring for ACHD patients should not only recognize the frequency of trait anxiety but also high-risk subgroups that may benefit from psychological or social interventions to reduce preprocedural anxiety.

A Novel Catheterization Laboratory Radiation Shielding System: Results of Pre-Clinical Testing.

BACKGROUND: This pre-clinical study evaluated the efficacy of a novel shielding system to reduce scatter radiation in the cardiac catheterization laboratory. METHODS: Using a scatter radiation phantom in a standard cardiac catheterization laboratory, a radiation physicist recorded radiation measurements at 20 reference points on the operator side of the table. Measurements were made with fluoroscopy and cine with the C-arm in the posterior-anterior (PA) and 40 degrees left anterior oblique (LAO) orientations. Scatter radiation doses were compared with and without use of the shielding system. RESULTS: Use of the shielding system was associated with >94.2% reduction in scatter radiation across all reference points in the PA and LAO projections with fluoroscopy and cine. With the shielding system, dose reductions at the location of the primary operator ranged from 97.8% to 99.8%. At locations of maximum scatter radiation, use of the shielding system resulted in dose reductions ranging from 97.8% to 99.8% with fluoroscopy and from 97.9% to 99.8% with cine. CONCLUSIONS: In this pre-clinical study, a novel radiation shielding system was observed to dramatically reduce scatter radiation doses. Based on these results, clinical testing is warranted to determine whether the shielding system will enable operators and staff to perform interventional procedures with less radiation exposure that may obviate the need to wear standard lead apparel. INDEXING WORDS: Radiation safety; occupational health; occupational hazard.

Pandemic-Associated Delays in Myocardial Infarction Presentation in Predominantly Rural Counties With Low COVID-19 Prevalence.

Fewer ST-elevation myocardial infarctions (STEMIs) presentations and increased delays in care occurred during the COVID-19 pandemic in urban areas. Whether these associations occurred in a more rural population has not been previously reported. Our objective was to evaluate the impact of COVID-19 on time-to-presentation for STEMI in rural locations. Patients presenting to a large STEMI network spanning 27 facilities and 13 predominantly rural counties between January 1, 2016 and April 30, 2020 were included. Presentation delays, defined as time from symptom onset to arrival at the first medical facility, classified as ≥12 and ≥24 hours from symptom onset were compared among patients in the pre-COVID-19 and the early COVID-19 eras. To account for patient-level differences, 2:1 propensity score matching was performed using binary logistic regression. Among 1,286 patients with STEMI, 1,245 patients presented in the pre-COVID-19 era and 41 presented during the early COVID-19 era. Presentation delays ≥12 hours (19.5% vs 4.0%) and ≥24 hours (14.6% and 0.2%) were more common in COVID-19 than pre-COVID-19 cohorts (p <0.001 for both), despite a low COVID-19 prevalence. Similar results were seen in propensity-matched comparisons (≥12 hours: 19.5% vs 2.4%, p = 0.002; ≥24 hours 14.6% vs 0.0%, p = 0.001). In a predominantly rural STEMI population, delays in seeking medical care after symptom onset were markedly more frequent during the COVID-19 era, despite low COVID-19 prevalence. Considering delays in reperfusion have multiple adverse downstream consequences, these findings may have important implications in rural communities during future pandemic resurgences.